"every tooth's a snowflake"
TRANSCRIPT
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Treating Our Patients Using Endodontic and Implant Restorations
PPAC
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Treatment Numbers
Endodontic and implant restorations are performed daily by dentists and specialists
For endodontic treatment, estimates for the year 2000 were 30 million endodontic procedures annually (ADA)
Estimated number of patients receiving endosseous implants 1996 - 300,000-428,000 annually, 2000 - 910,000 annually future annual growth rate - 18.6%
(Millenium Research Group)
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Treatment Numbers
0
100
200
300
400
500
600
700
800
900
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Implant placement at University of Minnesota 1997-2007
Implants
Patients
40% increase annually
1997-2007
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Treatment Considerations
“Treatment planning for the future: Endodontics, fixed partial dentures – or implants?”
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Treatment Considerations
“The success rate of non-surgical root canal treatment is unclear within the endodontic literature.”
“…(endodontics) in general practice, the success rate can be 64% to 75%.”
“Endodontic therapy may extend the life of the tooth but very little is known on the extent of tooth longevity.”
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Implants vs. Endodontics
The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”
Iqbal MK, Kim S, 2007
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Implants vs. Endodontics
Furthermore, in response to an ADA Foundation request for proposals Torabinejad, et al, conducted a systematic review of the clinical, psychosocial, and economic outcomes of endodontics, implants and FPDs.
Torabinejad, et al, 2007
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Implants vs. Endodontics
Success criteria Problem areas Who’s treating Publication bias Modern advances
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Apples vs. Oranges
Success criteria Problem areas Who’s treating Publication bias Modern advances
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Implants vs. Endodontics
Success criteria Problem areas Who’s treating Publication bias Modern advances
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Success Criteria
Endodontic Criteria 1956, Strindberg proposes stringent
radiographic criteria Strindberg LZ, 1956
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Success Criteria
Endodontic Criteria 1956, Strindberg proposes radiographic
criteria Beginning in 1966 and since, many authors
suggest radiographic criteria is ill advised Bender IB, Seltzer S and Soltanoff W, 1966 Van Nieuwenhuysen JP, et al, 1994 Fristad I, et al, 2004 Gutmann JL, 1992 Seltzer S, 1988
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Success Criteria
Endodontic Criteria 1956, Strindberg proposes radiographic
criteria Beginning in 1966 and since, many authors
suggest radiographic criteria is ill advised However, some studies still use Strindberg’s
dated criteria. Allen R, Newton C and Brown C, 1991 Sundqvist G, et al, 1998 Sjogren U, et al, 1990 Farzaneh M, Abitbol S and Friedman S, 2004
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Success Criteria
Endodontic Criteria 1956, Strindberg proposes radiographic
criteria Beginning in 1966 and since, many authors
suggest radiographic criteria is ill advised However, some studies still use Strindberg’s
dated criteria. Fristad and colleagues showed the potential
for late radiographic healing. Fristad, Molven and Halse, 2004
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Success Criteria
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Success Criteria
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Endodontic Success Criteria
3-year recall
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Endodontic Success Criteria
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Endodontic Success Criteria
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Endodontic Success Criteria
12-month recall
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Success Criteria
1956, Strindberg proposes radiographic criteria
Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised
However, some studies still use Strindberg’s dated criteria.
Fristad and colleagues showed the potential for late radiographic healing.
Success or Survival? Iqbal MK, Kim S, 2007
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Success Criteria
Success or Survival? The definition of “success” for dental implant
studies is often implant survival Unlike implants and FPDs, RCTs aim to cure
existing disease Weiger, et al, 1998
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Success Criteria
Success or Survival? Unlike implants and FPDs, RCTs aim to cure
existing disease Thus, RCT studies measure both the healing
of existing disease and the occurrence of new disease.
Torabinejad, et al, 2007
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Success Criteria
Success or Survival? It has been suggested that implant success
criteria are not routinely applied in much of the implant outcomes literature
Salinas and Eckert, 2007
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Success Criteria
Success or Survival? “In essence, the use of lenient success
criteria in implant studies may translate to higher success rates, while stringent criteria employed in root canal prognostic studies may lead to lower success rates.”
Watson, et al, 1999 Johnson, et al, 2000 Wennstrom, et al, 2005
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Success Criteria
In order to establish comparable comparisons, it is critical that the same outcome measure is used to assess both endodontic and implant procedures.
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Success Criteria
In order to establish comparable comparisons, it is critical that the same outcome measure is used to assess both endodontic and implant procedures
Due to these differences in meanings of success, it is probable survival rates “will permit less biased, albeit less informative, comparisons.”
Doyle, et al, 2006 Eckert and Wollan, 1998 Creugers, et al, 2000 Torabinejad, et al, 2007
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Success Criteria
The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”
Iqbal MK, Kim S, 2007
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Success Criteria
Success or Survival? Iqbal MK, Kim S, 2007
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Success Criteria - Implants
Two 3.75 x 18 implants were placed on #9, 10 sites
Implants appear osseointegrated
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Initial visit pt presented with
provisional restorations
Success Criteria - Implants
Esthetics case referred to Dr. Debra Johnson
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Implants vs. Endodontics
Success criteria Problem areas Who’s treating Publication bias Modern advances
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Restorative Impact
Lazarski et al examined over 110,000 endodontic cases, and found teeth that were not restored were significantly more likely (>4 X) to undergo extraction.
Lazarski et al 2001
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Restorative Impact Lazarski et al examined over 110,000 endodontic
cases, and found teeth that were not restored were significantly more likely (>4 X) to undergo extraction.
The restoration of an endodontically treated tooth is considered a major determinant of its survival.
Vire DE, 1991 Siqueira JF, 2001 Hoen MM, Pink FE, 2002 Salehrabi R, Rotstein I, 2004 Aquilino SA, Caplan DJ, 2002 Sorensen JA, Martinoff JT, 1985
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Restorative Impact
The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”
Iqbal MK, Kim S, 2007
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Restorative Impact
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Restorative Impact
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Restorative Impact
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Restorative Impact
22-month recall
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Restorative Impact
The restoration of an endodontically treated tooth is considered a major determinant of its survival.
More prosthetic complications with implants. Goodacre CJ, et al, 2003 Iqbal MK, Kim S, 2007 Doyle et al 2006
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Bone Loss Around Implants
With implant placement, 1 mm of bone is loss during the first year of placement, with an additional 0.1mm annually.
Can vary with implant type/material
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Bone Loss Around Implants
0
1
2
3
4
0 1 2 3 4 5 6
Year
>
Bon
e Lo
ss (
mm
)
n=455 Error bars = S.E.M.
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Cost to Patient
Analysis of 2005 insurance data concluded that restored single-tooth implants cost 75-90% more than similarly restored endodontic-treated teeth
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Cost to Patient
Analysis of 2005 insurance data concluded that restored single-tooth implants cost 75-90% more than similarly restored endodontic-treated teeth
Post-treatment problems can increase this cost difference
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Cost to Patient
0
500
1000
1500
2000
Endodontic/Restoration Implant/Restoration
Ave
rage
Pric
e ($
$) 130%Increase
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Implants vs. Endodontics
Success criteria Problem areas Who’s treating Publication bias Modern advances
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Who’s Treating?
Historically, implants placed by specialists, while many endodontic studies were conducted on patients treated by dental students.
Aquilino SA, Caplan DJ, 2002 Bergman B, et al, 1989 Dammaschke T, et al, 2003 Lynch CD, et al, 2004 Mentink AG, et al, 1993
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Who’s Treating?
Of 13,047 identified studies, 147 articles from the endo, prosth and implant literature were systematically reviewed.
Torabinejad, et al, 2007
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Who’s Treating?
Of 13,047 identified studies, 147 articles from the endo, prosth and implant literature were systematically reviewed.
Torabinejad, et al, 2007
GPs or Specialists StudentsImplant 0% 87%Prostho 29% 35%Endo 63% 29%
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Who’s Treating?
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Who’s Treating?
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Who’s Treating?
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Who’s Treating?
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Implants vs. Endodontics
Success criteria Problem areas Who’s treating Publication bias Modern advances
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Publication Bias
More likely to exist when a particular brand of implant is studied. While endodontics is mostly generic.
Schnitman PA, Shulman LB, 1979 Iqbal MK, Kim S, 2007 Andersson B, et al, 1998 Brocard D, et al, 2000 Deporter DA, et al, 1998
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Publication Bias
More likely to exist when a particular brand of implant is studied. While endodontics is mostly generic.
Furthermore, 13% of the implant studies had an evaluator that was different than the operator, while 88% of the endo papers had independent evaluators.
Torabinejad, et al, 2007
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Publication Bias
More likely to exist when a particular brand of implant is studied. While endodontics is mostly generic.
Furthermore, 13% of the implant studies had an evaluator that was different than the operator, while 88% of the endo papers had independent evaluators
“… the authors' results confirm the presence of publication bias in implant dentistry literature…”
Moradi DR, et al, 2006
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Implants vs. Endodontics
Success criteria Problem areas Who’s treating Publication bias Modern advances
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Modern Advances
Both Iqbal and Kim’s as well as Torabinejad and colleagues’ systemic reviews were conducted “using material from previous decades and therefore reflect the treatment approaches prevalent at that time.”
Iqbal and Kim, 2007
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Modern Advances
Implants New implant shape/design New surface modifications New implant-abutment
interfaces Immediate loading Mini implants Etc…
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Modern Advances
Implants New implant
shape/design New surface
modifications New implant-abutment
interfaces Immediate loading Mini implants Etc…
Endodontics NiTi instrumentation Apex locators Surgical operating
microscope Digital radiography Materials: MTA,
MTAD, Resilon DNA hybridization,
PCR, etc… Etc…
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Case Selection
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Case Selection
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Case Selection
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Case Selection – Fx #20
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Case Selection
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Case Selection
1-month recall
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Case Selection
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Case Selection
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Case Selection
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Case Selection
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Case Selection
13-month recall
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Implants vs. Endodontics
The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”
Iqbal MK, Kim S, 2007
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Implants vs. Endodontics
The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”
Iqbal MK, Kim S, 2007
AND
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Implants vs. Endodontics
The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”
Furthermore, in response to an ADA Foundation request for proposals Torabinejad, et al, conducted a systematic review of the clinical, psychosocial, and economic outcomes of endodontics, implants and FPDs.
Torabinejad, et al, 2007
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Implants vs. Endodontics
“…in periodontally sound teeth having pulpal and/or periradicular pathosis, root canal therapy resulted in…equal outcomes (97%) to extraction and replacement of the missing tooth with an implant.”
Torabinejad, et al, 2007
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Implants vs. Endodontics
“No difference in the survival rates between the two treatment modalities.”
Iqbal MK, Kim S, 2007
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Implants vs. Endodontics
n=4477
Endo/Implant:Survival proportions
0 2 4 6 8 100.5
0.6
0.7
0.8
0.9
1.0
ImplantEndodontic
Time
Unpublished data from AAE Foundation - Bowles, Eleazer, Drum & Goodis 2008
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Implants vs. Endodontics
Endodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and or periradicular pathology.
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Implants vs. Endodontics
Endodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and or periradicular pathology.
Implants should be given priority in treatment planning for teeth that are planned for extraction
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Implants vs. Endodontics
The decision to treat a compromised tooth endodontically or replace it with an implant must be based on factors other than treatment outcome – since the outcomes are similar.
Iqbal and Kim 2008
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Implants vs. Endodontics
CASE SELECTION
CASE SELECTION
CASE SELECTION
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Conclusion
Functional survival rates are high for both treatments
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Conclusion
Functional survival rates are high for both treatments
Endodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implant
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Conclusion
Functional survival rates are high for both treatments
Endodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implant
Since outcomes are similar with either treatment, decisions should be based on other factors such as restorability, costs, esthetics, potential adverse outcomes and ethical factors